Mindfulness Based Cognitive Therapy for Depression

Essay/Review
of
Mindfulness Based Cognitive Therapy for Depression
An Eight-Week Course

When I lead retreats I often encounter people with depression who finds that meditation can help
them in some way. I thought it might be useful to make available a review cum essay about a new
method devised by Mark Williams, John Teasdale and Zindel Segal and explained in Mindfulness-
Based Cognitive Therapy for Depression: A new Approach to preventing Relapse. This book describes
an eight-weeks course for groups of patients who have suffered several occurrences of depression.
This review is to encourage people, who are interested in this topic, to read the book in case they
have not heard of it. Although relatively thorough this essay does not replace the book. It just gives a
taste and an idea of what the method entails.
The eight-week course is for groups of 12 people who have had depression and have recovered from
its acute phase. Each person has an initial private assessment interview of one hour before joining
the group. In the class people are regularly given handouts, tapes and recommended readings or
videos to watch. There are feedback, discussion and review times as empowerment is an essential
component of the course. One of the core aims of the course is for people to learn skills to help
prevent depression coming back. The skills to be learnt are: concentration, awareness, being in the
moment, acceptance, letting go, being rather than doing and bringing awareness to the
manifestation of a problem in the body. The aim of the program is freedom from self-inflicted
negative depressive patterns and to see how each person can creatively engaged with them.
The first week is focused on the cultivation of mindfulness. The intention is for participants to realize
that they are often on automatic pilot. The danger of living ones life on automatic pilot is that one
will also react automatically and thus be easily caught in destructive emotional and mental
patterning. They are taught to pay attention in a particular way: intentionally, in the present
moment and without judgment. This actually changes the nature of their experience. By practicing
mindfulness they becomes more aware of their experience in each moment and thus can really
engage with it and start to bypass the grooves of the patterns.
The participants end the first session with a short breath focus (two or three minutes) to ground
them after this first encounter with a lot of new material. The instructions are for them to sit with
their back straight, focus their attention on their breath as it enters and leaves the body, and notice
any sensations associated with the breath. They are also given some homework for the following
week like doing six times the body scan tape, bringing moment-to-moment awareness to one daily
routine activity and eating one meal mindfully. The homework is supported by a homework record
form which is to be filled each time the patients practice and which will help them discuss their
experience at the next session.
One patient reported that at first she found it difficult to concentrate as she kept thinking of other
things while listening to the body scan tape. But over time she started to relax more and by not
worrying about her distracted thoughts she had less of them, was able to be more present to the
exercise and be aware of her body and feelings in an accepting way.
Session two deals with the difficulties people might encounter when they try to be mindful: the
mind wandering, not finding the time or the right condition in which to do the exercises, being
bored, feeling of irritation, falling asleep, trying too hard or re-connecting with distressing emotions.
All these difficulties are discussed and investigated and it is pointed out that all these can become
beneficial places for non-judgmental mindfulness.
One specific difficulty is when the body scanning re-connects one with distressing emotions one
generally tries to avoid, as sometimes people have found safer to think about emotion than to
experience emotion in the body. There the instructor suggests that intentionally returning
awareness to the body scan instructions, and then following them by focusing on the specified
region of the body, as best as they can, provides patients with a way to steady themselves, while
still remaining connected to bodily experiences. The instructors believe that this will help in
allowing completion of the unfinished work of emotional processing. One participant was
concerned that she seemed to get worse after following the instructions for two weeks but actually
she found that over time the process reversed itself and she described that she felt that its all been
filed away now and it actually got better.
In session two, a thoughts and feelings exercise is introduced. The story presented is that of a
friend coming down the street and ignoring one and participants are asked to consider how they
would view this incident and how it would makes them feel. This exercise is to see that our
emotions are consequences of a situation plus an interpretation, that thoughts are not facts and that
negative thinking is often a warning signs of oncoming depression. In the discussion following this
exercise people realized that one situation can be interpreted in many different ways and according
to different interpretations one will have different feelings, and that a negative perception will lead
to a distressing feeling, specially if there is a fertile ground of depressive notions and patterns.
In this session creating a pleasant events calendar is suggested as an exercise in mindful awareness
of what is and can be positive in ones life. This can act as a counterweight to the tendency of
thinking that everything is difficult and unpleasant. At the end of the session there is again a
meditation focusing on the breath to develop a still and calm awareness in which thoughts, feelings
and sensations can come and go. The homework for the following week is to continue to use the
Body Scan tape, to practice ten--fifteen mindfulness of breathing for six days, to fill the Pleasant
Events Calendar with one entry per day and to choose a new routine activity to be especially mindful
of daily.
The third session emphasizes the focusing on the breath as a tool to steady and ground oneself in
daily life. The participants do a thirty to forty minutes sitting meditation. After which they receive
recommendations on the Three-Minute Breathing Space. This exercise will become one of the main
tools of awareness and refuge in their daily life. The Three-Minute Breathing Space has to happen
three times a day. There are three basic steps (called Awareness, Gathering and Expanding) to be
done at set times: first asking oneself Where I am? or Whats going on? as a means to bring
oneself back to attention in the present moment. The second step consists in bringing the attention
to the breath. The third step is to expand the attention to include a sense of the breath and the
body as a whole. In MBCT the awareness of the body is seen as an important anchor, which
steadies one and allows one to be less caught in mental ruminations.
At this stage mindful stretching and walking are introduced as well as an unpleasant events calendar.
The task is to notice as clearly as possible the thoughts, feelings and bodily sensations associated
with unpleasantness in order to learn to relate differently to them. The homework is to use the
Combined Breath Focus Tape three times, follow yoga instructions three times, practice the Three-
Minute Breathing Space and complete the Unpleasant Events Calendar (one entry per day).
The fourth session is about working with the comparing mind and the mind that clings or avoids.
Mindfulness of sounds and thoughts is introduced. An automatic thoughts questionnaire is given to
reflect on and note the thoughts that occur repeatedly over the week and color ones view of reality
like:
Im no good.
Ive let people down.
I feel so helpless.
Its just not worth it.
The questionnaire contains thirty such thoughts. The participants are also presented the Diagnostic
Criteria for Major Depressive Episode i.e. the inability to experience pleasure, sleeplessness,
fatigue or feelings of worthlessness, etc symptoms, which have lasted for more than two weeks.
The instructors believe that education about depression is essential if people are going to learn
ways to deal with it more skillfully. One of the symptoms of depression is for people to feel alone in
it, by looking at these criteria as a group, patients discover the commonality of the symptoms of this
illness. It is not only them who feel or experience themselves that way. The difficult with the
questionnaire is that it might make people feel even sadder as they recognize and identify with some
of these thoughts. Then the idea is to take a Three-Minute Breathing Space as a means to experience
the sadness in a different manner.
By week four the participants are starting to feel the benefits from all this practice, their dedication
and commitment. One mentioned that she felt sad because of her grandmother illness. She was able
to recognize that she was tired and sad because of this condition and that this was not depression.
So she could be with the feelings and the thoughts without denial and thus could let them pass
through her. Another had to make a distressing phone call and instead of ruminating all day about it,
at the end of it, she did the breathing space exercise and it allowed her to move on and for the
worry to vanish.
The homework, that week, is to practice the Guided Sitting Meditation Tape, six out of the next
seven days, do the Three-Minute Breathing Space as a rule three times but on top of that use it to
cope whenever unpleasant feelings are noticed.
Session five focuses on acceptance and on cultivating a different relationship to experience. In the
forty minutes meditation participants are encouraged to let difficulty issues come up in the mind
and instructions are given to help one become aware of their effects in the body and to let go of
the aversion. A poem of Rumi whose theme is acceptance of the whole person and of his or her
experience is read.
There are further practice and homework reviews. People explore the difference between using the
breath to escape, fix or avoid, which does not seem to really help, or using the breath to
acknowledge fully and to accept what one is experiencing, which seems to bring a significant change.
People notice that the first approach gives energy to the resistance and the latter one brings space
to what one is feeling and as Michael, a patient, mentioned: you feel that everything isnt out of
control. The homework is to continue with the sitting practice alternating listening to a tape and
just sitting in silence, and with the Three-minute Breathing Space as a regular and coping practice.
In session six negative moods and thoughts are explored and it is pointed out that thoughts are not
facts. Meditation on thoughts is introduced. There is also a moods, thoughts, and alternative
viewpoints exercise. The Breathing Space is presented as the first step before taking a wider view
of thoughts. One of the difficulties with depression is that people are over-engaged with their
thoughts and have long ruminative discussion with themselves. So in this session it is shown that one
does not need to answer back ones own thoughts. One participant found that she really benefited
from telling herself that thoughts are not facts even the ones that tell you they are. It helped her
to engage more playfully and light-heartedly with her ruminative thoughts.
The homework consists in meditating a minimum of forty minutes a day in different self-appointed
chunks, and in continuing with the practice of the Breathing Space. Patients are also asked to notice
when they use the breath as an anchor to handle the situation as it is happening and when they
use the mindfulness practice to deal with issues later.
In session seven people are preparing for the future after the eight-week session ends. Now they
need to focus on the positive in their life and what uplifts their moods. In order to do that they have
to become aware of the connection between what they do and how they feel. It helps if they write
down a list of what bring them joy and what demonstrate to them that they are good at doing
something. They are encouraged to plan how best to schedule such activities.
They are also asked to recognize the warning signals of a future relapse irritability, decreasing
social participation, change in sleeping or eating habits, etc. It is essential for them to map out the
actions they can undertake to prevent the recurrence of a depressive state. The homework is to
decide on the form of meditation one wants to do in the next five weeks on a regular basis and to
continue with the regular and coping practice of the Three-minute Breathing Space. To prevent
relapse the recommendations is to set up an Early Warning System and to prepare an Action
Plan reminding oneself of the tools one has cultivated during the course.
Session eight is an opportunity to review the whole course and for participants to reflect on what
they have experienced and what they have learnt. People relate how the course has allowed them
to learn to slow down and to find an inner safety devoid of criticism, which helps defuse negative
mental thoughts before they cause any more damage. Some pointed how affirming it had been
doing the course with other people who know what depression is like. Other found the breath
meditation especially beneficial. One discovered an inner strength, another felt that doing the
course had removed a sense of shame.
One person realized that they did not need to worry about the future and their past failures, that
it was much more rewarding to live in the present. Now that person could more evenly and calmly
embrace the present moment and thus learn from it to prevent further recurrence of depression.
At the end of the course two handouts are given, one about using what has been learned to deal
with future moods and the other about how to cultivate daily mindfulness. The core advice
people are being given is to KEEP BREATHING with awareness.